QA Investigation Results

Pennsylvania Department of Health
DAILY DOVE CARE LLC
Health Inspection Results
DAILY DOVE CARE LLC
Health Inspection Results For:

This is the only survey for this facility

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Initial Comments:
Based on the findings of an onsite unannounced state license complaint investigation survey completed October 13, 2022, Daily Dove Care, Llc, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.


Plan of Correction:




Initial Comments:


Based on the findings of an unannounced complaint investigation survey completed on October 13, 2022, Daily Dove Care, Llc, was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.


Plan of Correction:




611.53(a) LICENSURE
Child Abuse Clearances

Name - Component - 00
A home care agency or home care registry that serves persons under 18 years of age shall require each applicant for employment or referral as a direct care worker, each applicant for employment as a member of the agency or registry office staff to request a ChildLine verification regarding whether the applicant is named in the Statewide Central Register as the perpetrator of a founded or indicated report of child abuse as defined at 55 Pa. Code 3490.4 (relating to definitions).

Observations:


Based on review of personnel files (PF) and interview with office Manager the agency failed to ensure direct care workers requested a Childline verification when in direct contact with children while providing services for five (5) of six (6) files reviewed. PF #1, #2, #3, #5 & #6.

Findings include:

Review of personnel files (PF) completed on 10/13/22 between approximately 10:30-11:30 AM revealed:
PF#1, Date of Hire (DOH): 3/9/22 contained no documentation of Childline verification despite being in direct contact with children while providing care to the consumer.
PF#2, (DOH): 6/21/22 contained no documentation of Childline verification despite being in direct contact with children while providing care to the consumer.
PF#3, (DOH): 2/11/22 contained no documentation of Childline verification despite being in direct contact with children while providing care to the consumer.
PF#5, (DOH): 1/12/22 contained no documentation of Childline verification despite being in direct contact with children while providing care to the consumer.
PF#6, (DOH): 11/19/19 contained no documentation of Childline verification despite being in direct contact with children while providing care to the consumer.


Interview with the Agency Office Manager completed 10/13/22 at approximately 12:30PM confirmed the above findings.













Plan of Correction:

Starting 11/01/2022, Agency Administrator will have every client and every direct care worker sign off on Minors in Home Reporting policy during intake applications and training moving forward. They will need to report if minors are in the consumer's home within 48 hours of providing care to the consumer. During the intake process, consumers will be responsible for reporting if they have minors in the home.
Direct Care workers with completed ChildLine verification will be input into Google sheet to monitor who can fill shifts with children in the home.
Starting 11/01/2022 the Agency coordinators will review new applications and confirm if Direct Care Worker will need to complete the child clearance process to the HR Team. The HR Team, if needed, will complete child clearance prior to Direct Care Worker providing services. This policy will be implemented throughout the agency and will be included in annual training. This application review will be for new employees.
In the event it is reported that the consumer has minors in the home, the Direct Care Worker without documented Childline verification will be removed from providing services immediately. Services will continue to be provided by Agency Direct Care Worker with Childline verification already completed, until the results of original direct care worker allow for them to return to work.



611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on review of personnel files, and interview with Agency Manager the agency failed to ensure the direct care workers sucessfully completed a trainng program meeting the standards imposed on the agency by virtue of the agency's participation as provider of a Medicaid waiver program for four (4) of six (6) files reviewed. PF #1, #2, #4 & #5.

Findings include:


Review of personnel files (PF) completed on 10/13/22 between approximately 10:30-11:30 AM revealed:
PF#1, Date of Hire (DOH): 3/9/22 contianed no documentation of completion of a training program.
PF#2, (DOH): 6/21/22 contained documentation of a written competency test without a score.
PF#4, (DOH): 6/14/22 contained documentation of a written competency test without a score.
PF#5, (DOH): 1/12/22 contained documentation of a written competency test without a score.



Interview with the Agency Office Manager completed 10/13/22 at approximately 12:30PM confirmed the above findings.












Plan of Correction:

Starting 10/24/2022 HR Supervisor has set up a DocuSign system to automatically grade competency tests and populate the score for each completed test.
DocuSign will notify staff when a score is less than 85% to connect with Direct Care Worker to properly understand the competency training and resubmit for the test.
Beginning date 10/17/2022, Agency administrator will audit All Direct Care Workers tests to confirm they are graded and have met the competency requirements.
If they are not graded, staff will grade and reach out to DCW if the score does not meet competency test requirements.
Beginning 11/15/2022 Agency HR Supervisor will begin monthly audits to confirm Docusign System is properly reporting grading for competency tests.